New York State Improperly Claimed Medicaid Reimbursement for Some Adult Day Health Care Services

The New York State Department of Health (State agency) claimed Medicaid reimbursement for some Medicaid adult day health care (ADHC) services that did not comply with certain Federal and State requirements. Of the 100 claims in our random sample, the State agency properly claimed Medicaid reimbursement for 60 claims. However, the State agency claimed Medicaid reimbursement for services that were unallowable for the remaining 40 claims. On the basis of our sample results, we estimated that the State agency improperly claimed at least $70 million in Federal Medicaid reimbursement for ADHC services that did not comply with certain Federal and State requirements.

We recommended that the State agency refund $70 million to the Federal Government and improve its monitoring of the ADHC program to ensure that providers comply with Federal and State requirements for: (1) examining and assessing beneficiaries before admitting them to the ADHC program, (2) providing ADHC services in accordance with individualized care plans, (3) maintaining documentation to support services billed, (4) reevaluating beneficiaries for their continued stay in the ADHC program in a timely manner, and (5) claiming reimbursement only for services actually provided.

In written comments on our draft report, the State agency disagreed with our first recommendation, and said that the New York State Office of the Medicaid Inspector General (OMIG) would work with the Centers for Medicare & Medicaid Services to resolve seven claims associated with our draft report's second recommendation. After reviewing the State agency's comments and additional documentation submitted by OMIG under separate cover, we modified our findings, statistical estimates, and recommendations accordingly.